1. Cracking the Case: Quick, Easy OMT in a Nutshell
Jessica Kelner, DO
Brian Browning, DO
Family Medicine
Neuromuscular Medicine

2. Today’s lecture 3 musculoskeletal cases Differential Diagnosis
Documentation and Billing for OMT
Pertinent anatomy and special tests
3 OMT treatments for each case
Lab after each case

3. Case 1 - HPI
35 year old female c/o intermittent progressively worsening headaches x 1 month.
3-4x a week, worse when she is stressed, better with lying down and closing her eyes
Headaches start in the back of her head on the right and radiate around toward the back of her right eye.
Pain is “achy” and “sharp” behind her eye, rates them as a 7/10.
Associated discomfort on right side of her neck.
Tried taking ibuprofen and Excedrin which helps for an hour or two.

4. Case 1 She denies recent head trauma. No association with menstruation
ROS: +headache, +right sided neck pain, denies numbness or tingling, denies blurry vision,+ Light sensitivity when she gets the headaches. denies N/V/D/F, denies weakness, denies fatigue
All other ROS are negative

5. Medical History
Medical History: seasonal allergies, no past history of headaches or motion sickness as a child.
Surgical History: none
Medications: zyrtec 10mg during allergy season, ibuprofen 600mg every 6 hours as needed for headache
Family History: Mom – headaches, HTN
Social History: works as a secretary, drinks 2 cups of coffee/day, processed food diet, no exercise, non smoker, lives with husband

6. Physical Exam GEN: Well-nourish, well-hydrated. NAD
Temp: 98.8 deg F BP: 128/75 Pulse: 70 Ht: 66inches Wt: 160lbs
GEN: Well-nourish, well-hydrated. NAD
HEAD: normocephalic, atraumatic
ORO-PARYNX: mucus membranes mildly dehydrated, clear, no exudates
EYE: PERLA, EOMI
LUNGS: CTA B/L, no wheezing or rhonchi
CV: RRR, no M/R/G
Abd: Soft, NT/ND, no organomegaly
NEURO: sensation in b/l upper extremities in-tact to light touch
PSYCH: A&O x 3, judgment, memory and insight intact

7. Physical Exam
MSK
hypertonic paraspinal muscles in thoracic spine and cervical spine B/L
hypertonic trapezius B/L
hypertonic levator scapula B/L
decreased cervical lordosis
hypertonic anterior and middle scalenes B/L
TTP over right occipital condyle with reproduction of symptoms
ROM of head: decreased rotation to the right compared to the left, otherwise full ROM of neck, neck is supple
Negative Spurling’s test

8. Osteopathic Exam
Patient was found to have tenderness, asymmetry, restriction of ROM, and tissue texture changes in the following areas:
HEAD: OA compression on the right, with TTP over occipital condyle
CERVICAL SPINE: C2 Flexed RRSR
anterior and middle scalenes restriction Right, Right SCM restriction
THORACIC SPINE: T2 Flexed SLRL
B/L trigger points in upper trapezius

9. Differential Diagnosis
Tension headache
Migraine headache
Dehydration
Cerebral aneurysm
Meningitis
Viral syndrome
Trigeminal neuralgia
Pseudotumor cerebri
Giant Cell Arteritis

10. Diagnosis Allopathic Assessment and Plan
Tension headache (G44.209)
Muscle spasm of paraspinal muscles (M62.838)
Heating pad
Stretching exercises for upper back and neck
Increase oral fluid intake
Diclofenac PRN
Osteopathic Assessment and Plan
Somatic Dysfunction of Head Region (M99.00)
Somatic Dysfunction of Cervical Region (M99.01)
Somatic Dysfunction of Thoracic Region (M99.02)
OMT to 3 Body Regions (98926)

11. Billing for this Visit
(E/M level 3 establish patient office visit)
- 25 modifier on E/M code for other separate procedure (OMT)
98926 (3-4 Body Regions Treated)

12. Billing Tips Evaluation and Management Codes: Modifier CPT codes
99202, 99203, most often used for new patients
99212, 99213, most often used for established patients
Modifier
25 for “separate and identifiable procedure done the same day”
CPT codes
98925 (OMT to 1-2 body regions)
98926 (OMT to 3-4 body regions)
98927 (OMT to 5-6 body regions)
98928 (OMT to 7-8 body regions)
98929 (OMT to 9-10 body regions)

13. Greater Occipital Nerve
Originates from C2 spinal
Between C1 and C2, along with the lesser occipital nerve
Emerges inferior to the suboccipital triangle  (obliquus capitis inferior) muscle
Passes through the trapezius muscle and ascends to innervate the skin along the posterior scalp to the vertex of the head

15. Greater Occipital Nerve

16. OMT Techniques OA decompression Muscle Energy for Cervical Spine
Muscle Energy for the shoulder girdle
Upper Thoracic Soft Tissue

17. OA Decompression
Used for abnormal tension, hypertonicity or spasm of the cranial base that can interfere with cranial-sacral functioning
Releases tissues around the jugular foramen thus enhancing fluid drainage from the cranial vault and reducing intracranial fluid congestion.
Restores normal vagal tone.
Can also benefit the glossopharyngeal nerve, and the spinal accessory nerve.

18. OA Decompression Physician: seated at the head of patient
Patient: supine
Place fingers vertically (pointing toward ceiling) so that the patient’s sub-occipital area is balanced on the physicians fingertips. The pads of the fingers should maintain contact with this area.
The weight of the patient’s head is the only therapeutic force applied.
As tissues relax, maintain pressure, until you can palpate the posterior arch of the atlas (C1).
Continue pressure to slowly disengage the atlas from the occiput. Disengagement will be noted by a “floating sensation” of the atlas
As the atlas floats, balance it, support it with the tips of your ring finger while moving the occiput gently in a cephalad direction with the tips of your middle fingers. This will further disengage the occiput from the atlas and decompress the condylar region.

19. Cervical Spine Muscle Energy

20. Cervical Spine Muscle Energy
Dysfunction (C2 F RRSR)
Physician: seated at the head of the table
Patient: supine
Cradle the patient’s head in your hands and palpate the articular pillars at the level of C2
Extend the patient’s head until motion is felt under your palpating fingers
Rotate the patient’s head to the left until motion is felt under your palpating fingers
Sidebend your patient to the left at C2 by translating C2 to the right with your left finger (creating left sidebending)
Instruct the patient to attempt to bring their head toward their right ear (right sidebending) while providing isometric resistance for 3-5 seconds
Instruct the patient to relax while easing your counterforce
Reposition to a new restrictive barrier by increasing flexion, left rotation and left sidebending
Repeat 3-5x or until no further progress is made
Re-check

21. Shoulder Girdle Muscle Energy

22. Shoulder Girdle Muscle Energy
Patient: seated or supine
Physician position: standing (if patient is seated) or seated (if patient is supine)
Used to assist in relaxation of the superior head of trapezius
Contact AC joint and ipsilateral neck with hands and have patient shrug shoulder against counterforce.
Have the patient relax, take up the slack, and repeat 2 more times or until tissues soften

23. Seated Soft Tissue

24. Upper Thoracic Soft Tissue
Can be done in any position (supine, prone, lateral recumbant or seated)
Primarily used to address the root of the neck
Also to some degree addresses sympathetic innervation (especially if used in conjunction with rib raising)